sbwmhp

WOUND MEDICINE NEW PATIENT EVALUATION
WOUND MEDICINE CONSULTATION REPORT

DATE OF INITIAL EVALUATION:
??

??REFERRING SOURCE:
??

CONSULTING PHYSICIAN:
Bill Khoury, MD

REASON FOR EVALUATION AND PRESENTING COMPLAINT:
Nonhealing wound ??

HISTORY OF PRESENT ILLNESS:
The patient is a ??-year-old ??male who presents to the Saddleback Memorial Center for Advanced Wound Healing for an initial visit for evaluation and treatment of ??


PAST MEDICAL HISTORY:
??

CURRENT MEDICATIONS:
During today's encounter, I used all immediate resources available to me to review the patient's current medications:
??

ALLERGIES:
??None known.

SOCIAL HISTORY:
??

REVIEW OF SYSTEMS:
CONSTITUTIONAL:  No recent weight loss.  No fevers, chills, or sweats.

HEENT:  Normal hearing.  No nasal congestion.  No dysphagia.  No vision changes or eye pain.

RESPIRATORY:  No cough or shortness of breath.

CARDIOVASCULAR:  Denies chest pain or palpitations.  No new lower extremity swelling.

GASTROINTESTINAL:  No nausea, vomiting, or diarrhea.  No abdominal pain.

GENITOURINARY:  Denies dysuria or hematuria.

NEUROLOGIC:  No focal weakness.  No mental status changes.  No new numbness or sensory change.

SKIN:  Please refer to history of present illness.

EXTREMITIES AND MUSCULOSKELETAL:  Please refer to history of present illness.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature ??, pulse ??, respirations ??, blood pressure ??

CONSTITUTIONAL:  M?? is alert, calm, cooperative, oriented x4, and in no acute distress.

HEENT:  Atraumatic.  Normal mucous membranes.  Eyes:  No redness.  Anterior chambers are clear.

CARDIOVASCULAR:  Cardiac:  Regular rhythm.  No murmurs or extra sounds.  No jugular venous distention.  Vascular:  ??.

RESPIRATORY:  Clear bilaterally.  No wheezing.  Normal respiratory effort.

GASTROINTESTINAL:  No tenderness or masses.  Bowel sounds active.

MUSCULOSKELETAL:  No joint pain or swelling.  Color of gaiter area is normal.  Please refer to wound exam.

DERMATOLOGIC:  No rashes.  Please refer to wound exam.

NEUROLOGIC:  Mental status within normal limits.  No focal weakness or facial asymmetry.

WOUND EXAMINATION:
Wound #:  ??
Location:  ??
Measurements:  ??
??

MEDICAL DECISION MAKING:
Diagnostic data:  ??

Procedures:  ??

??OPERATIVE REPORT:
??

ASSESSMENT:
??

PLAN:
1.         Therapeutic interventions:  As discussed above.
2.         Consultation and surgeries:  None are planned at this time.
3.         Diagnostic testing:  ??
4.         Followup:  Followup visit in one week.

DIAGNOSTIC IMPRESSION:
??

CONDITION ON DISCHARGE:
Stable.